Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakland Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure that LPNs had the specific competencies and skill sets needed to care for residents' needs. Surveyors requested competency evaluations for 5 randomly selected LPNs, and the DON stated that no skills competencies had been done for any of them.
Failure to Ensure Daily RN Coverage: Surveyors found that the facility did not ensure an RN was on duty for at least 8 consecutive hours every day. Review of staffing schedules and unit assignment sheets showed that on two days no RN worked any part of the day, and the DON confirmed the missing RN coverage during interview.
Failure to Maintain a Data-Driven QAPI Program: The facility did not maintain a comprehensive QAPI plan or a systematic, data-driven QAPI process. The NHA, who chaired the QAPI committee, could not provide the formal QAPI plan, could not explain how audit data was analyzed or trended, and repeatedly stated that the committee simply "talk[ed] about it." The facility had no benchmarks, trend analysis, or evidence of ongoing performance monitoring, and the DON stated she was not aware the facility was expected to systematically track and analyze QAPI data.
Unsafe sidewalk and patio conditions were observed, with buckled concrete, broken sections, holes, and large gaps in the patio, along with grading that caused water to pool at the entry door. Two surveyors had roller bags catch in the same sidewalk holes, and a resident's wheelchair wheel had previously become lodged in a hole, nearly pitching the resident forward. The NHA, DON, and Maintenance Director all acknowledged the long-standing issues, prior complaints, and that required weekly rounds from the prior POC were not being completed.
The facility failed to ensure care plan interventions were in place for residents with fall risk and respiratory needs. A resident with dementia and weakness had a fall mat listed in the care plan, but none was observed in the room; another resident with a prior fall and hip fracture had an anti-roll back device added to the care plan, but the wheelchair did not have the device in place. A third resident with COPD was receiving oxygen, but the care plan did not address oxygen use until after surveyor intervention.
Missing Required GNA Training Documentation: Record review and staff interviews showed that required abuse, dementia, and infection control training was not documented for 3 of 5 GNAs reviewed. The DON and HR Director were unable to provide sufficient evidence of the missing training before survey exit.
Two residents with cognitive impairment and pain were not provided with appropriate pain management. One resident with advanced dementia had multiple documented pain assessments indicating discomfort, but there was no evidence that staff addressed the pain. Another resident who fell and showed signs of pain was transferred to the hospital without documented pain management, later being diagnosed with a pelvic fracture. The DON confirmed the lack of pain management in both cases.
Failure to maintain a resident's grooming and dignity occurred when a resident with severely impaired cognition and maximal assistance needs was repeatedly observed with facial hair on the chin and upper lip. The resident stated a preference to be shaved, while the care plan did not reflect any preference to wear facial hair. A GNA confirmed the resident needed staff help with shaving, and the DON stated the facial hair should have been shaved if that was the resident's preference.
Failure to Obtain Informed Consent for Psychoactive Medication: A resident with stroke history, heart disease, and non-Alzheimer's dementia had a surrogate decision maker identified and was deemed unable to understand documents due to dementia. The record showed consent documentation for Remeron that did not include the responsible representative, and later Seroquel was started for delusions and hallucinations without documentation that the resident or representative was informed of the risks before the antipsychotic was initiated. No consent form for Seroquel was found in the chart.
Advance directive and MOLST documentation were incomplete for a resident with dementia, heart disease, and lung disease. The chart noted an advance directive had been reviewed, but no advance directive or HCPA was found, SW notes did not show discussion with the resident or a responsible representative, and the MOLST lacked documentation of who consented to no CPR and other life-sustaining treatment orders. The incapacity form was also incomplete, with the second physician section left blank and the DON noting unusual handwriting on the MOLST’s second page.
A resident with dementia, heart disease, and lung disease had ongoing significant weight loss that was not timely communicated to the PCP or RD. The resident lost 5% in one month, then continued to decline to a 12% loss over two months and an 18.1% loss over five months, while provider notes repeatedly failed to address the significance of the weight loss or document awareness of the continued decline.
Failure to timely process and track grievances: A resident's family member repeatedly raised concerns about damaged sidewalks and standing water at the entry, including an incident where the resident's wheelchair became stuck in a hole. The NHA, who served as grievance officer, knew about the issue but did not follow up because no formal grievance was submitted, and the complaint was not entered into the grievance log despite staff reporting that multiple people had voiced concerns.
The facility failed to provide or document written transfer notices and bed-hold information for two residents who were sent to the hospital. Staff referenced CCDs and bed-hold forms, but records did not show the transfer notice was given, the CCD was sent, or that the bed-hold paperwork was completed. One resident was transferred after a fall, and another was sent to the ER for GI symptoms; in both cases, required documentation was missing or incomplete.
Inaccurate MDS ROM Assessment: A resident with a history of stroke and left-sided paralysis had contractures and impaired ROM noted in observation and therapy records, but the MDS first recorded no ROM limitations and later documented one-sided ROM inconsistently with OT and PT findings. An MDS nurse confirmed the ROM impairment was inaccurately reported on the MDS.
Failure to document that the baseline care plan was provided to residents after admission. Three residents had no record showing the baseline care plan was shared with the resident or representative within the required timeframe. The DON stated the plan is usually presented by the DON or SW, but the chart lacked documentation, and an SW confirmed she did not review it with one resident.
Failure to Provide Oral Care to a Dependent Resident: A resident who depended on staff for all self-care needs was observed with dry, crusted lips, and the condition remained present on a later observation. The MDS and care plan showed the resident required staff assistance with oral hygiene, but staff did not ensure the resident’s oral care needs were met when the issue was first observed.
Failure to provide an ongoing activity program that met a resident’s needs and preferences. A bed-bound resident with dementia and severely impaired cognition was observed lying in bed, yelling, and not participating in activities. The resident’s MDS and care plan identified preferred activities such as news, music, fresh air, animals, and religious services, but activity logs showed only newspaper/puzzle handouts, and an activity aide stated these were not given to cognitively impaired residents because they did not understand what was going on.
The facility failed to ensure proper follow-up after a resident’s hospital discharge for a Foley catheter and failed to document orders or care plan interventions for an air mattress used by another resident. The resident returned from the hospital after septic shock related to a catheter-associated UTI and severe AKI, with discharge instructions to follow up with urology to discuss a suprapubic catheter or outlet procedure, but staff could not confirm the follow-up was completed and an appointment was later found to have been cancelled without rescheduling. For a second resident at risk for pressure injury, an air mattress was observed in use, but the record contained no current order or care plan direction for its setting or monitoring.
Failure to maintain ROM for a resident with left-hand paralysis: A resident with stroke-related left-hand paralysis had repeated OT findings of impaired ROM in the upper extremities and visible left-hand contractures with no device in place during observation. OT discharge documentation did not show services or treatments to prevent further decline after therapy discharge, and a hand roll/washcloth order was later started then discontinued; staff were unsure why the ordered nighttime positioning device had stopped.
A resident with a colostomy related to ischemic bowel had a care plan directing staff to provide colostomy care per policy, which required assessment of the peristomal skin. Record review found no evidence that the stoma site or surrounding skin were routinely assessed, and an LPN said she provided colostomy care and documented it, but the chart did not support that care. The DON stated aides typically changed and emptied the pouch while licensed nurses typically assessed the peristomal site, but there was no documentation showing licensed nurses provided the resident’s colostomy care.
A resident receiving G-tube feedings had the formula bottle and tubing observed multiple times without dates or labels, despite an order requiring them to be dated and labeled with each change. Two LPNs confirmed the setup was unlabeled and undated, and one noted that staff might not know how long it had been running. The DON stated that nursing staff were expected to date and label the bottle and tubing before hanging them.
A resident with COPD was observed receiving oxygen via nasal cannula at 1 L on an oxygen concentrator, even though the attending physician’s order called for 2 L. An LPN confirmed the setting was incorrect and noted the concentrator’s filter was dirty. The DON stated staff were expected to administer oxygen according to physician orders.
Failure to ensure required PCP visits and address significant weight loss. A resident with dementia, heart disease, and lung disease was not seen face-to-face by the PCP every 30 days during the first 90 days after admission, and the PCP notes did not address repeated significant weight loss. The resident lost weight from 144 lbs to 135.7 lbs, then to 126.2 lbs, and later had an RD note documenting an 18.1% loss over 5 months; the PCP documentation also incorrectly stated there had been no recent falls.
The facility failed to keep refrigerated controlled drugs in separately locked, permanently affixed compartments in two medication storage rooms. In one unit, an Ativan box was stored in an unlocked refrigerator with the key kept inside the fridge, and in another unit a locked narcotic box was also placed in an unlocked refrigerator and could be removed. The facility policy required scheduled meds and other drugs subject to abuse to be stored in a separate, permanently affixed area under double lock.
A resident with dementia, heart disease, and lung disease had oxygen orders that were not accurately reflected in the medical record or consistently followed by staff. The chart showed conflicting documentation about whether oxygen was nightly, continuous, or PRN, while observations found the resident without oxygen at times and staff gave inconsistent explanations about the order. The TAR and care plan also documented oxygen use as continuous, despite the physician order not matching that description.
A deficiency was cited when a facility area was found to contain accident hazards and lacked sufficient supervision to prevent accidents, resulting in an unsafe environment for residents.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
The facility did not complete daily checks on the AED for a significant number of days, despite manufacturer instructions and expectations from the DON and Administrator. Nursing staff interviews revealed confusion about responsibility for these checks, and there was no specific facility policy in place.
The facility did not ensure that a resident was protected from abuse, neglect, or punishment by any individual, resulting in a deficiency related to resident safety and well-being.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
LPN Competency Evaluations Not Completed
Penalty
Summary
The facility failed to ensure that licensed nurses had specific competencies and skill sets necessary to care for residents' needs. During the annual survey staffing task, surveyors requested skills and competency evaluations for 5 randomly selected LPNs: Staff #12, #13, #14, #15, and #16. When the DON was interviewed, she stated that there were no skills or competencies for any of the 5 LPNs and explained that no skills competencies had been done. No further evidence was provided by the end of the survey.
Failure to Ensure Daily RN Coverage
Penalty
Summary
The facility failed to ensure there was a Registered Nurse (RN) on duty for at least 8 consecutive hours every day. During the annual survey, staffing schedules were reviewed for 22 days, and the deficiency was identified on 2 days. On 12/08/25, surveyors requested nursing staffing schedules for 12/08/25 through 12/21/25 and later reviewed the schedules, which showed that some days had no scheduled RN. The DON stated that there was at least one RN scheduled for each weekend shift and that administrative RNs, including herself, the MDS nurse, and the IP nurse, were in the building during the week. She also stated that she was the weekend supervisor but was on call and did not come to the facility on weekends, and that all licensed nurses worked 12-hour shifts. She further stated that the facility had a staff scheduler who had started 5 days earlier. On 12/11/25, the DON provided a binder of daily staffing meetings and unit assignment sheets for 11/16/25 through 12/07/25. Review of the unit assignment sheets showed that on Sunday 11/23/25 and Sunday 12/07/25, no RNs worked any part of either day. On 12/12/25, the DON was interviewed again and confirmed that the facility failed to have an RN work any part of 11/23/25 or 12/07/25. No further evidence was provided by the end of the survey.
Failure to Maintain a Data-Driven QAPI Program
Penalty
Summary
The facility failed to ensure that its QAPI committee maintained a comprehensive, data-driven program. During the entrance conference, the surveyor requested the facility QAPI plan, but it was not provided within the requested timeframe. When the NHA was asked for the plan, he was uncertain about the difference between QAPI policies and the formal QAPI plan and stated he would work on getting it. Over the next several days, he remained unable to provide the QAPI plan, and the surveyor instead reviewed Leadership Policies and Procedures that described QAPI responsibilities such as collecting, analyzing, tracking, and trending data, prioritizing problem-prone areas, implementing corrective actions, conducting root cause analyses, and reporting monthly consolidated data to the Executive Board. During interviews, the NHA confirmed that he chaired the QAPI committee and was responsible for oversight of the QAPI program, but he could not describe a data-driven process. He stated that the committee met with appropriate personnel to discuss topics identified from prior issues, morning or afternoon meetings, or concerns brought to leadership. When asked about the hydration issue identified during the October 2025 complaint survey, he provided audit documentation but could not explain how the data had been analyzed, what conclusions were reached, or what actions resulted, stating, "we just talk about it." He confirmed that the facility did not maintain data, benchmarks, or trend analysis and had not conducted any required PIPs. The NHA further stated that the facility did not track or analyze adverse events or medical errors and did not use such information to implement preventive actions. He was unable to provide audit tools or documentation from the prior year other than audits completed after the October 2025 complaint survey, and he confirmed there was no additional evidence of audits, data tracking, or performance monitoring. Although he later provided a document titled QAPI Overview and identified focus areas such as hydration, abuse and neglect, AED monitoring, and nursing education, he was still unable to show how audit data was analyzed, trended, or used to monitor the effectiveness of corrective actions. The DON also provided a QAPI outline and stated that a Falls PIP had been conducted, but she was unsure whether the data was tracked and stated she was not aware the facility was expected to systematically track and analyze data as part of the QAPI program.
Unsafe Sidewalk and Patio Conditions
Penalty
Summary
The facility failed to maintain sidewalks and a patio in a safe condition for residents, staff, and the public. Surveyors observed multiple sidewalk and patio defects, including buckled concrete, broken sections, holes, and very large gaps in the patio surface. The surveyor also noted that the lawn grading sloped toward the building entrance, contributing to water accumulation at the entry door during rain events. During observations, two surveyors reported incidents in which their roller bags caught in holes in the same sidewalk, causing one bag to abruptly lodge and pull from the surveyor's hands and causing the other surveyor to stumble when the bag was propelled from their hand. A family member of Resident #5 reported that the resident's wheelchair wheel had previously become lodged in a hole in the sidewalk, nearly causing the resident to be lunged forward from the chair. The family member also reported ongoing concerns about the sidewalks and standing water at the entry door, stating these concerns had been reported to facility staff for several months and that no corrective action or follow-up had occurred after the NHA was informed. Facility staff and leadership acknowledged the longstanding condition of the sidewalks and patio. The Maintenance Director stated he knew the areas needed repair, had requested approval for repairs, and that corporate offices had not authorized them. The NHA stated he was aware of the sidewalk and patio issues, knew water pooled at the front door when it rained, and confirmed that he had not completed the weekly sidewalk and patio rounds required by the prior Plan of Correction from the 2023 citation. The DON stated the sidewalk had been an issue for many years, prior patching had not been effective, and earlier repair quotes had been considered too expensive, so repairs were not completed.
Failure to Implement Care Plan Interventions and Complete Resident Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan and failed to ensure that care plan interventions were implemented for residents with identified needs. Resident #3, admitted in June 2025, had a care plan for fall risk related to weakness and dementia that was updated in October 2025 to include a fall mat to the right side of the bed. However, the resident was observed in bed on 12/8/25 and again on 12/11/25 with no fall mats observed on either side of the bed, and the nurse confirmed there was no fall mat in the room. The record also showed the resident had two falls during the look-back period, including one on 11/21/25 when the resident was found on the floor beside the bed, but the documentation did not show whether the fall mat was in place at that time. Resident #2 had a facility-reported incident on 9/1/25 when the resident attempted to pick up a book from the floor and fell out of the wheelchair, sustaining a hip fracture that required surgical repair. The corrective action in the final report included an anti-roll back device to the wheelchair, and the care plan for falls was updated to include that intervention. Yet on 12/11/25 the resident was observed seated in a wheelchair without an anti-roll back device in place, and the therapy director confirmed the device was not on the wheelchair and could not be found. For Resident #49, who had COPD and an order for oxygen at 2 L/min via nasal cannula, the resident was observed receiving oxygen at 1 L/min, and the care plan did not address oxygen use until after surveyor intervention; staff confirmed the care plan had lacked this information.
Missing Required GNA Training Documentation
Penalty
Summary
The facility failed to provide required training for Geriatric Nursing Assistants (GNAs) as evidenced by record review and staff interviews during the annual survey. Training records were requested for 5 randomly selected GNAs, and review of the records showed that GNA #8 had no documented abuse, dementia, or infection control training, GNA #9 had no documented abuse or infection control training, and GNA #10 had no documented infection control training. On 12/12/25, the DON was asked whether any additional evidence of training existed for these GNAs and stated that Human Resources might have documentation. The Human Resources Director was then interviewed twice and stated she would look and had contacted the agency the GNAs worked for to see if training records could be provided, but no sufficient evidence was submitted before survey exit.
Failure to Manage Pain for Residents with Cognitive Impairment and After Injury
Penalty
Summary
The facility failed to adequately manage pain for two residents with cognitive impairments. For one resident with end-stage dementia and chronic pain, the care plan required staff to use the PAINAD scale for pain assessment due to the resident's inability to verbally express pain. Despite multiple documented instances where the resident was assessed as experiencing pain at varying levels, including a high pain score of 8, there was no evidence in the medical record that staff took action to manage the resident's pain on those occasions. The director of nursing confirmed the absence of documentation regarding pain management interventions following these assessments. In another case, a resident who experienced a fall and subsequently exhibited signs of pain, such as limping and guarding, was not provided with pain management prior to being transferred to the hospital. The facility's investigation and review of the resident's records did not show any documentation of pain management before the hospital transfer, despite the resident later being diagnosed with a right pelvic fracture. The director of nursing acknowledged that pain management was expected but not documented or provided before the resident's transfer.
Failure to Maintain Resident Grooming and Dignity
Penalty
Summary
The facility failed to ensure that a resident who required assistance with self-care was groomed in a manner that preserved dignity. Resident #12, who had severely impaired cognition and required maximal assistance from staff with personal hygiene, was observed on multiple occasions seated in a wheelchair with facial hair on the chin and upper lip. The resident remained unshaved during observations in the hallway and later at the nurses' station, despite needing staff help with all other self-care needs except propulsion in the wheelchair and feeding. Record review showed that the resident's care plan did not reflect a preference to wear facial hair. During interview, the resident stated a desire to have the facial hair shaved. A GNA reported that the resident required staff assistance with shaving and other personal care, and acknowledged that the facial hair should have been addressed long before. The DON stated that she expected the resident's facial hair to have been shaved if the resident preferred it shaved.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that the risks and benefits of psychoactive medication were discussed with the resident and/or the responsible representative before treatment was started. Resident #20 was admitted in February 2024 with diagnoses including history of stroke, heart disease, and non-Alzheimer's dementia. The resident had a surrogate decision maker identified, and on 3/5/24 was deemed incapable of understanding information contained on documents and forms due to dementia prior to stroke. A Consent for Psychoactive Medication form was completed for Remeron and indicated verbal consent, but it did not document that the resident's responsible representative was informed or consulted regarding the medication. The medical record also showed that on 5/2/24 a psychiatric provider evaluated the resident for delusions and hallucinations and noted the resident was receiving Remeron and Prozac, with a plan to start Seroquel 25 mg twice daily. The consent form listed side effects and risks associated with antipsychotic medications, but the record did not show documentation that the resident or the responsible representative was informed of the risks before Seroquel was started. A progress note on 5/4/25 confirmed Seroquel was started, and on 12/10/25 the resident still had an active order for Seroquel twice daily. No Consent for Psychoactive Medication form was found for Seroquel, and when the DON was asked about informed consent on 12/12/25, no additional documentation was provided before survey exit.
Advance Directive and MOLST Documentation Not Completed
Penalty
Summary
The facility failed to ensure that residents or their responsible representatives were asked about advance directives and that responsible decision makers were involved in determining orders for CPR and other life-sustaining treatment options for one resident reviewed for advance directives. The resident was admitted with diagnoses including dementia, heart disease, and lung disease. The PCP’s admitting history and physical stated that an advance directive had been reviewed, but the medical record did not contain an advance directive or documentation of a health care power of attorney, and the Social Worker notes did not show that advance directives were discussed with the resident or a responsible representative. The resident’s MOLST form included orders for no CPR, no artificial ventilation, no artificially administered fluids or nutrition, no dialysis, and limits on hospital transfer and medical tests. However, the record did not document who these orders were discussed with or who gave informed consent. The PCP signed the first page of the MOLST, but the second page was dated separately and the name of the PCP was handwritten in different handwriting; the DON stated she did not recognize the handwriting on the second page. The resident was also found by the attending PCP to be unable to understand or evaluate treatment decisions, with a recommendation that healthcare decisions be made by a third-party decision maker, but the second physician section on the incapacity form was left blank.
Failure to Notify PCP and RD of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the primary care physician and the registered dietitian were made aware of continued significant weight loss in a timely manner for one resident with dementia, heart disease, and lung disease. The resident’s weight decreased from 144 lbs to 135.7 lbs, which represented a significant 5% loss in one month, but the PCP note did not acknowledge or address the loss. The RD note later documented the weight loss and noted recent treatment for a urinary tract infection and improved intake, with a plan to monitor intake and weights. The resident continued to lose weight, with a recorded weight of 126.2 lbs on 9/1/25, reflecting a 12% loss over two months, and there was no documentation that the RD or PCP were notified of this continued significant loss. The resident was later seen by the PCP, whose note mentioned weight loss monitoring but did not address the significance of the ongoing decline. Additional weights showed further loss to 124.6 lbs and then 118.2 lbs, totaling an 18.1% loss over five months. Documentation did not show the RD was aware of the continued significant weight loss until 11/8/25, and the PCP note on 11/30/25 stated weights were reviewed but did not address the significant weight loss since admission.
Failure to Timely Process and Track Grievances
Penalty
Summary
The facility failed to enter, investigate, and follow up on a grievance in a timely manner. During the Resident Council task, surveyors identified that 1 of 1 grievances reviewed in the facility's grievance log did not reflect the sidewalk concerns reported by a resident's family member, even though those concerns had been voiced to staff and the Nursing Home Administrator (NHA) over several months. The grievance notice posted in the facility stated that grievances could be filed orally or in writing and that the facility used three business days to investigate and resolve grievances. A resident's family member reported ongoing concerns about the condition of the facility sidewalks and the pooling water at the front entry door. The family member described an incident in which the resident's wheelchair wheel became lodged in a hole in the sidewalk and nearly caused the resident to be lunged from the chair. The family member stated that the concerns had been reported to facility staff for months and that they had directly informed the NHA about the issue approximately one month earlier, but no corrective action or follow-up had occurred. The family member stated they would next contact the corporate office because the NHA had largely ignored the concerns. The NHA acknowledged awareness that the sidewalks and patio required repairs and that water pooled at the front door during rain. He also confirmed that he served as the grievance officer and that the family had voiced concerns to the receptionist, but he did not follow up with the family member because they had not officially turned in a grievance. Staff reported that the family member had complained after the wheelchair incident and that both the Maintenance Director and NHA were notified, but no grievance form was provided for the complaint. Review of the grievance log showed seven grievances for 2025 and none related to the sidewalk concerns, and the NHA confirmed that no sidewalk grievance had been entered. The facility policy required leadership to accept grievances from residents and family members, act promptly to resolve them, and track grievances through conclusion.
Missing Transfer Notice and Bed-Hold Documentation
Penalty
Summary
The facility failed to ensure that written transfer notices and bed-hold policy information were provided to residents and their responsible parties when residents were transferred to the hospital. This deficiency was identified for two residents reviewed for hospitalizations. The record review and interviews showed that the required transfer documentation was not found in the medical record for either resident, and staff were unable to show that the information had been provided at the time of transfer. For one resident, the medical record showed the resident fell and was sent to the hospital, but there was no documentation that a written transfer notice or bed-hold policy was given to the resident or responsible party. Staff described use of a Continuity of Care Document (CCD) and a paper bed-hold document, but the nurse interviewed was unfamiliar with a transfer notice. The CCD contained information for the receiving institution, but the record did not show that it was sent with the resident. The DON confirmed the facility sends the CCD when residents are transferred, but could not verify that it was documented as sent. For the other resident, the record showed the resident was sent to the ER for nausea, vomiting, intermittent constipation, and abdominal pain, and the emergency contact was notified. Survey review found no evidence that the resident or representative received written transfer notification or a bed-hold notice. The facility later produced an incomplete temporary leave bed-hold form that lacked key information, including the date, room number, anticipated return date, and witness signature. The DON confirmed that the transfer notice could not be located and acknowledged that the incomplete bed-hold documentation and missing transfer notice were concerns.
Inaccurate MDS ROM Assessment
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for one resident reviewed for position and mobility. An observation of the resident revealed contractures in the left hand, with fingers bent at the knuckle joints and unable to straighten, and the resident was unable to lift both hands. Record review showed a hospital history and physical documenting a stroke in 2022 with left-sided paralysis, and an admission observation noting contractures in the left upper and lower extremities and the right lower extremity. Further review showed an OT evaluation documenting impaired ROM in the left shoulder, elbow, forearm, and wrist, but the admission MDS recorded no functional limitations in ROM of any upper or lower extremities. Later OT and PT evaluations documented impaired ROM in both upper and lower extremities, yet the resident’s MDS assessment documented one-sided ROM in the left and right extremities. In interview, the MDS nurse stated that impaired ROM documentation on the MDS involved reviewing therapy evaluations and notes, and confirmed that the resident’s ROM impairment was inaccurately reported on the MDS.
Failure to Document Baseline Care Plan Provided After Admission
Penalty
Summary
The facility failed to ensure that baseline care plan information was provided to the resident and/or a responsible representative within 48 hours of admission for 3 residents out of 15 reviewed. Review of Resident #20’s medical record showed the resident was admitted in February 2024, but there was no documentation that the baseline care plan information was provided to the resident or a responsible representative. Review of Resident #3’s medical record showed the resident was admitted in late June 2025, but again no documentation was found showing the baseline care plan was provided to the resident or a responsible representative. Review of Resident #55’s medical record showed the resident was admitted on [DATE], but the record did not contain documentation that the baseline care plan was provided to the resident or the resident representative. The DON stated that the baseline care plan is usually completed and presented to the resident between 24 and 48 hours after admission and that either she or social services presents the information, but confirmed this should be documented in the medical record. The DON later stated that social work may have given the baseline care plan to the resident, but there was still no documentation to support that it had been provided, and the SW confirmed she did not review the baseline care plan with the resident.
Failure to Provide Oral Care to a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for all self-care needs received oral care. Resident #6 was observed lying in bed with dry, crusted lips on 12/8/2025 at 9:34 AM, and staff #19, an LPN, later confirmed the lips were dry and crusted and said they needed to be cleaned with a swab. On 12/9/2025 at 8:55 AM, the crusted areas on the resident’s lips were still present. Record review showed an MDS dated 11/21/25 documenting that Resident #6 relied on staff for all self-care needs, and the ADL care plan identified that the resident required staff assistance with oral hygiene and that staff would assist with oral hygiene as needed. In interview on 12/9/2025 at 1:56 PM, staff #19 stated she attempted to remove the crust from the resident’s lips after the surveyor’s intervention, but it was not easy to remove at that time and could only be removed later after applying petroleum.
Failure to Provide Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and preferences of one resident. Resident #6 was bed-bound, had dementia, and severely impaired cognition. During multiple survey observations, the resident was seen lying in bed, yelling, and not involved in any activity. The resident’s representative stated that the resident was not engaged in activities. The resident’s admission MDS showed that it was very important to do preferred activities, including keeping up with the news, going outside for fresh air when the weather was good, listening to music, being around animals, and participating in religious services or practices. The care plan identified that the resident was dependent on staff to meet emotional, intellectual, physical, and social needs and included interventions such as music, religious/spiritual one-to-one visits, reading during one-to-one visits, and being outdoors. However, the activity logs from October 1 to December 8, 2025 showed only Chronicle/puzzle as the activity provided, with participation recorded as U. An activity aide stated that Chronicle/puzzle meant handing newspapers and puzzles to residents, but also stated that this was not done for cognitively impaired residents because they did not understand what was going on. The Activity Director acknowledged the concern regarding the lack of activities based on the resident’s identified preferences.
Failure to Ensure Hospital Follow-Up and Air Mattress Orders
Penalty
Summary
The facility failed to ensure appropriate follow-up care after a hospital discharge for a resident with a Foley catheter. The resident had a care plan for indwelling catheter use related to bladder neck obstruction, and after a hospital transfer for dark red blood in the catheter and a drop in hemoglobin, the resident returned with discharge instructions for follow-up with urology in two weeks to discuss a suprapubic catheter versus an outlet procedure. The record also showed the resident was admitted to the hospital for septic shock related to catheter-associated pseudomonas and enterococcus UTI and severe AKI. The resident later stated that the hospital doctor had suggested specialist follow-up for a suprapubic catheter, but the resident had not heard any follow-up and believed something else was supposed to be done. The record review and interviews showed the facility did not ensure the discharge recommendation was carried out. A nurse documented that the resident wanted to talk to someone about surgery for a suprapubic catheter, but the DON and nursing staff could not recall the discharge instruction. The DON stated the nurse on the return-from-hospital shift should have reviewed the instructions and notified her so the appointment could be made. Later review showed the resident was seen by urology and recommended to have a cystoscopy, but the DON could not confirm whether it had been scheduled. Staff later reported that a urology/cystoscopy appointment had been scheduled and then cancelled by the facility, with no documentation that it was rescheduled. The facility also failed to ensure there were orders or care plan interventions for the use and monitoring of an air mattress for another resident at risk for pressure injury. The resident had a care plan for pressure ulcer/injury risk related to immobility, decreased cognition, kidney failure, heart disease, and fragile skin, and an air mattress was observed on the bed and turned on. However, review of physician orders and the care plan did not reveal documentation for the air mattress, including what setting it should be on or that staff were checking it regularly. Nursing staff and the DON confirmed there was no current order in the record for the air mattress, and the DON stated she did not see one in the electronic health record.
Failure to Maintain ROM for Resident With Left-Hand Paralysis
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received treatment and services to prevent further decline in range of motion. Resident #6 was admitted with left-hand paralysis due to a stroke in 2022, and an OT evaluation dated 5/16/2025 documented impaired ROM in the left upper extremity, including the shoulder, elbow/forearm, wrist, and hand. During an observation on 12/8/2025, the resident’s left hand had contractures with fingers bent at the knuckle joints and unable to straighten, and no device was in place. A licensed practical nurse present at the time stated the resident did not wear any device on the left hand and was unable to open the resident’s fingers. Record review showed that the resident had multiple OT evaluations documenting continued impaired ROM in the left upper extremity, including evaluations dated 7/31/25 and 10/7/25. The OT discharge summary did not document services or treatments implemented to prevent further decline after discharge from therapy, and the review also noted impaired ROM in the right upper extremity. The resident was discharged from OT on 11/10/25 with a recommendation for a hand roll/washcloth to be placed on the left hand for 5 hours every night. The treatment administration record showed an order for a rolled-up washcloth to the left hand was initiated on 11/10/25 and discontinued on 11/17/25. A GNA stated the resident used to receive a rolled towel on the left hand but did not know why it stopped, and the therapy manager stated the resident was to use a rolled towel for 5 hours each night and was unsure why the provider’s order had been discontinued.
Colostomy Care Not Properly Documented or Assessed
Penalty
Summary
The facility failed to ensure that colostomy care for one resident was provided by appropriately trained, competent, skilled nursing staff. The resident was admitted with a colostomy related to ischemic bowel since May 2025, and the care plan included an intervention beginning 6/4/25 directing staff to care for the colostomy per facility policy. The facility policy for ileostomy/colostomy care required staff to assess the peristomal skin around the stoma. Record review found no evidence that the resident’s stoma site or surrounding skin were routinely assessed by staff. An LPN stated she provided colostomy care by checking the site for leaking or air and said she documented the care in the medical record, but review of the record showed no documentation supporting that she provided the care. The DON stated that nurses’ aides typically changed and emptied the colostomy bag and that licensed nurses typically assessed the peristomal site, but there was no supporting documentation showing that licensed nurses cared for the resident’s colostomy.
Unlabeled and Undated G-Tube Feeding Setup
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident receiving tube feeding. Resident #6 had been in the facility since May 2025 and required G-tube feeding for nutritional support. The provider’s order directed Osmolite 1.5 to be administered via the G-tube pump at 65 mL/hr for 24 hours daily, with special instructions to date and label the tubing with each change. During observations, the resident’s tube feeding was seen infusing at 65 mL/hr, but the formula bottle and tubing were not dated or labeled. This was observed on multiple occasions, and staff present, including two LPNs, confirmed that the tubing or bottle was unlabeled and undated. One LPN stated that if it is not dated, someone might not know how long it has been running. The DON later stated that nursing staff were expected to date and label the formula bottle and tubing before hanging them for residents.
Failure to Follow Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to follow an attending physician’s order to administer oxygen to Resident #49, who had chronic obstructive pulmonary disease. During an observation on 12/8/2025 at 8:50 AM, the resident was lying in bed and receiving oxygen via nasal cannula connected to an oxygen concentrator set at 1 L. A later observation with staff #19, an LPN, confirmed that the oxygen was set at 1 L even though it should have been set at 2 L. Staff #19 also checked the filter on the back of the oxygen concentrator and stated that the dirty filter was probably why the oxygen was on 1 L. Record review showed an attending physician’s order, initiated on 3/3/25, for oxygen at 2 liters per minute via nasal cannula for COPD. The DON stated that staff were expected to administer oxygen in accordance with attending physician orders.
Failure to Ensure Required PCP Visits and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by the PCP every 30 days during the first 90 days after admission. The resident had diagnoses including dementia, heart disease, and lung disease. The PCP completed the admitting H&P more than 5 weeks after admission, and the note for that initial visit was recorded later. The resident’s weight decreased from 144 lbs to 135.7 lbs, an 8.3 lb loss representing 5% in one month, but the 8/3/25 PCP note did not acknowledge or address the significant weight loss. The resident continued to lose weight, with a recorded weight of 126.2 lbs on 9/1/25, reflecting an additional 9.5 lb loss and a total loss of 12% of body weight in two months. No documentation was found that the RD or PCP were notified of the continued significant weight loss. The resident was seen by the PCP only twice in the first 90 days of admission, with more than 8 weeks between visits, and the later note also failed to address the significance of the weight loss or provide a plan. After a fall on 11/21/25, the RD documented an 18.1% weight loss over 5 months and recommended Magic Cup twice daily, but the PCP note on 11/30/25 still did not address the weight loss and incorrectly stated the resident had not fallen in the past 4 weeks.
Improper Storage of Refrigerated Controlled Drugs
Penalty
Summary
The facility failed to have separately locked, permanently affixed compartments for the storage of controlled drugs that required refrigeration, and this was observed in both medication storage rooms. In Unit 2’s medication storage room, the medication refrigerator contained a locked box used for Ativan when needed for a resident, but the refrigerator door did not have a locking mechanism and the box was not permanently affixed inside the refrigerator. The key to the narcotic box was kept inside the unlocked refrigerator, attached to the shelf on the door, and the nurse was observed removing the box from the refrigerator and unlocking it with that key. In Unit 4’s medication room, a locked narcotic storage box was also observed inside an unlocked refrigerator, and the nurse confirmed that the box could be removed from the refrigerator. The facility’s policy stated that scheduled medications and other drugs subject to abuse are to be stored in a separate, permanently affixed area and under double lock.
Inaccurate Oxygen Documentation and Administration
Penalty
Summary
The facility failed to ensure the medical record accurately reflected a resident’s need for and use of supplemental oxygen. Resident #3 was admitted with diagnoses including dementia, heart disease, and lung disease. The resident had physician orders in effect for oxygen at 2 liters per minute via nasal cannula nightly and another order for oxygen at 2 liters per minute via nasal cannula with instructions for staff to measure oxygen saturation before administration. However, the 7/25/25 order did not state that oxygen was to be given as needed or include oxygen saturation parameters. During observation, the resident was seen in bed and later asleep in a geri-chair without oxygen being administered, despite the presence of an oxygen concentrator next to the bed on one occasion. The medical record also did not consistently match the resident’s oxygen use. The PCP note from 8/3/25 did not document oxygen use, while the care plan was updated on 12/9/25 to address oxygen needs related to COPD and stated that oxygen was to be administered per physician order. That same evaluation note stated the resident used oxygen at 2 liters continuously, and the TAR documented oxygen administration during both day and night shifts along with oxygen saturation levels each shift, all at or above 92%. When questioned, one nurse stated the order should have been for oxygen as needed and that the resident did pretty well without oxygen, while another nurse said the care plan update was based on the TAR showing continuous oxygen use. The 7/25/25 oxygen order was later discontinued and replaced with a new order for oxygen at 2 liters per minute via nasal cannula continuous at night and during the day to keep oxygen saturation greater than 90%.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. These conditions directly contributed to the deficiency cited by surveyors.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Perform Daily AED Checks
Penalty
Summary
The facility failed to perform daily checks on the automated external defibrillator (AED) for 157 out of 421 days, as required by the manufacturer's periodic maintenance instructions. The maintenance insert specified that the AED should be checked to ensure the indicator was green, the battery was charged, prompts and display were functioning, pads were ready, all buttons worked, and the case was intact. Interviews with nursing staff revealed inconsistent understanding of responsibility for performing these checks, with some nurses stating it was not their duty. The Director of Nursing confirmed that daily checks were expected but acknowledged there was no specific facility policy, only reliance on the manufacturer's instructions. The Administrator also stated an expectation for daily checks to ensure equipment was functioning and stocked.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that there was an incident or incidents where a resident or residents were not safeguarded from such harm, as required by regulations. The report does not provide specific details about the actions or inactions of staff or others, nor does it mention the medical history or condition of the resident(s) involved at the time of the deficiency.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 89 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garrett County Subacute Unit | 0.5 mi | ★★★★★ | 0 | 0 |
| Dennett Rehab Center | 1.1 mi | ★★★★★ | 22 | 0 |
| Majestic Care Of Hopemont | 6.7 mi | ★★★★★ | 30 | 0 |
| Kingwood Healthcare Center | 15.2 mi | ★★★★★ | 6 | 0 |
| Cortland Acres Health And Rehabilitation | 19 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oakland Nursing & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.